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Asian Journal of Psychiatry 8 (2014) 5658

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Asian Journal of Psychiatry


journal homepage: www.elsevier.com/locate/ajp

A study of disability and its correlates in somatization disorder


Vijeta Kushwaha, Koushik Sinha Deb, Rakesh K. Chadda *, Manju Mehta
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 4 July 2013
Received in revised form 15 October 2013
Accepted 28 October 2013

Objective: The present study was conducted to assess disability, and its demographic and clinical
correlates in patients suffering from somatization disorder.
Method: Sixty-six patients, diagnosed as somatization disorder according to ICD 10 Diagnostic Criteria
for Research (ICD 10-DCR), were assessed for disability using the Indian Disability Evaluation and
Assessment Scale (IDEAS). Patients were also assessed for associated anxiety, depression, neuroticism
and subjective distress using the Hamilton Rating Scale for Anxiety (HAM-A), Hamilton Rating Scale for
Depression (HAM-D), PGI Health Questionnaire N2 (PGIN2), and Visual Analog Scale, respectively.
Results: Mean age of the sample was 34.5  5.8 years. Females constituted about 60% of the sample. Mean
duration of illness was 9.14  4.13 years. More than 70% of the subjects suffered moderate to severe
disability. Age, number of symptoms, duration of illness, and scores on HAM-A and HAM-D showed a positive
correlation with disability.
Conclusion: Somatization disorder is associated with signicant disability which increases with the
number of somatic symptoms, duration of illness, associated depressive and anxiety symptoms.
2013 Elsevier B.V. All rights reserved.

Keywords:
Disability
Somatization disorder
Anxiety
Depression
Neuroticism

1. Introduction

2. Materials and methods

Somatization disorder is the most severe representative of the


somatoform disorders. Functional impairment and disability
associated with somatoform disorders is comparable with that
seen in major depression and anxiety disorders (Bass et al., 2001;
Smith et al., 1986; Harris et al., 2009; Zoccolillo and Cloninger,
1986), and may even out weigh schizophrenia (Krishnan et al.,
2013). Patients with somatization disorder are reported to have
even greater functional impairment in several domains compared
to other somatoform disorders (Smith et al., 1986; Hiller et al.,
1997; Katon et al., 1991; Escobar et al., 1998). Role impairment in
somatizing patients results in high utilization of health care
services (Smith et al., 1986; Fink et al., 1999; Hansen et al., 2002).
Although the phenomenon of somatization is well studied in
the scientic literature, somatization disorder has not received
much attention from the researchers, probably due to its low
prevalence, especially from the Indian subcontinent (Chadda and
Bhatia, 1990; Chadda et al., 1993). The present study was planned
to assess the disability associated with somatization disorder in
Indian patients and explore its relation to demographic and clinical
correlates.

2.1. Selection of subjects

* Corresponding author at: All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110029, India. Tel.: +91 1126593236/26593245;
fax: +91 11 26589787x8663.
E-mail addresses: drrakeshchadda@gmail.com, drparveenchadda@gmail.com
(R.K. Chadda).
1876-2018/$ see front matter 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajp.2013.10.016

The study was conducted in a psychiatric outpatient clinic of a


tertiary care teaching general hospital in New Delhi, India.
Consecutive patients attending the walk in clinic of the hospital
on four specic days a week, who presented with multiple physical
symptoms without any apparent physical cause for duration of more
than two years, were screened for the study. Patients were recruited
over a period of 14 months from January 2007 to February 2008.
Inclusion criteria for the study were age between 1850 years,
with a diagnosis of somatization disorder as per the International
Classication of Diseases, 10th revision, Diagnostic Criteria for
Research (ICD-10-DCR). Patients with any signicant physical
illness, pregnancy, mental retardation, organic brain disorder,
psychotic disorder and substance use disorder (excluding nicotine
use) were excluded from the study.
2.2. Assessments
The study followed a cross sectional design. Socio-demographic
details and illness related information was recorded. Outcome
measures like disability, somatic symptoms and neuroticism,
subjective distress, depression and anxiety were assessed using
structured instruments.
Disability was assessed using the Indian Disability Evaluation
and Assessment Scale (IDEAS) (Rehabilitation Committee of the

V. Kushwaha et al. / Asian Journal of Psychiatry 8 (2014) 5658

Indian Psychiatric Society, 2002; Mohan et al., 2005). PGI Health


Questionnaire N2 (PGIN2) was used to assess neuroticism and
somatic symptoms (Verma and Wig, 1976). Depression was
assessed on the Hamilton Rating Scale for Depression (HAM-D)
17-item version (Hamilton, 1960) and anxiety was assessed on
the Hamilton Rating Scale for Anxiety (HAM-A) (Hamilton, 1959).
Subjective distress was rated on Visual Analog Scale (VAS)
measuring from 0 (no current distress) to 10 (severe distress).
The study was approved by the Institute Ethics Committee.
A written informed consent was taken from all the subjects.
2.3. Statistical analysis
Socio-demographic and illness related variables and scores on
outcome measures (disability, distress, depression, anxiety and
neuroticism) were tabulated. Correlation analysis was performed
to determine the relation between socio-demographic, illness
parameters and outcome variables. Stepwise linear regression was
performed to assess the effect of these variables on the total
disability of the patient. Data was evaluated using STATA 11
statistical package compatible with Windows.
3. Results
Sixty-six patients were recruited for the study. Patients were
mostly young adults of both genders, with mean age of 34.5 (SD
5.8, range 2045) years. Most of the patients belonged to urban
settings. More than 70% of the subjects were from lower socio
economic background and lived in nuclear families. Seventy three
percent of the patients had been referred from the other services of
the hospital, mostly from internal medicine, neurology and
gastroenterology. Only four patients had come directly to our
service, whereas about one fth had been referred from the health
services outside our hospital (Table 1).
The subjects had been symptomatic for a mean duration of nine
years (SD 4.13). Number of symptoms varied from 6 to 16, and the
subjects had sought an average of eight consultations (mean  SD
7.90  4.48). The current visit was the rst psychiatry consultation
for nearly 70% of the subjects.
Most patients reported mild to moderate levels of associated
depression and anxiety, though none suffered from comorbid
depressive or anxiety disorders. Most had high neuroticism scores
on PGIN2 Questionnaire with a mean score of 28 (SD 4.64) and also
received high distress scores (mean 8.52, SD 0.67) on the VAS
(range 010). All the subjects suffered some degree of disability,
with a majority (71.2%) falling in the category of moderate severity
on IDEAS (score: 813) (Table 1).
Bivariate analysis of categorical variables did not reveal any
signicant difference in the disability scores across various
sociodemographic groups. However, on correlation analysis,
disability scores showed an increase with increasing age
(p = 0.0000) and duration of illness (p = 0.0001). A positive
correlation was also observed with anxiety (p = 0.01) and
depressive symptoms (p = 0.006), and treatment seeking behavior
(p = 0.0000). A positive correlation was observed between age, and
duration of illness (p = 0.0000) and number of prior consultations
(p = 0.0000). Depression/anxiety scores also positively correlated
with increasing symptomatology, increasing duration and with
increase in disability scores (Table 2).
Data was subjected to multivariate analysis to adjust for the
effect of covariance of these variables. Stepwise linear regression
was performed and backward elimination technique was used to
determine the model of best t. In full model analysis, total
number of prior consultations was the only variable that
signicantly affected the outcome i.e. IDEAS score, when adjusted
for other variables. The model showed a Goodness of Fit

57

Table 1
Socio-demographic and clinical parameters in study population (n = 66).
Characteristics

Units

Values

Age in years

Mean  SD

34.5  5.8

Gender
Male
Female

N (%)
N (%)

27 (40.9)
39 (59.1)

Present occupational status


Professional/semi-professional
Shop owner/farmer/skilled worker
Semiskilled/unskilled worker
Homemaker
Not gainfully employed

N
N
N
N
N

(%)
(%)
(%)
(%)
(%)

4 (6.1)
15 (22.7)
10 (15.2)
34 (51.5)
3 (4.5)

Education level (years of education)


No formal education
<5 years of school education
612 years of school education
>12 years (college education)

N
N
N
N

(%)
(%)
(%)
(%)

13
12
30
11

Present marital status


Single
Married

N (%)
N (%)

15(22.7)
51(77.3)

Family type
Nuclear
Joint/extended

N (%)
N (%)

48 (72.7)
18 (27.3)

Place of residence
Urban
Rural

N (%)
N (%)

57 (86.4)
9 (13. 6)

Socioeconomic status
Low
Middle

N (%)
N (%)

47 (71.2)
19 (28.8)

Referral
Self
Internal medicine
Neurology
Gastroenterology
Other specialists
Other medical services

N
N
N
N
N

4 (6.06)
23 (34.84)
8 (12.12)
11(16.67)
6 (9.09)
14 (21.21)

Duration of illness
No. of prior consultations
No. of symptoms
IDEAS score
HAM-D score
HAM-A score
PGIN2 score
VAS score

Mean  SD
Median (range)
Median (range)
Mean  SD
Mean  SD
Mean  SD
Mean  SD
Mean  SD

9.14  4.13
7(218)
8(616)
8.30  2.43
12.72  2.50
13.89  3.01
28  4.64
8.52  0.67

Degree of disability on IDEAS


Mild disability
Moderate disability
Severe disability

N (%)
N (%)
N (%)

18 (27.27)
47 (71.21)
1 (1.52)

(%)
(%)
(%)
(%)
(%)

(19.7)
(18.2)
(45.4)
(16.7)

HAM-D, Hamilton Depression Rating scale; HAM-A, Hamilton Rating Scale for
Anxiety; VAS, Visual Analog Scale.

coefcient (R2) of 0.41, suggesting that 41% of the variability of


the disability is explained by these factors and had probability
F = 0.0012, establishing that the model was valid. Using backwards elimination technique, the model that best tted the
variability of IDEAS score consisted of four variables: duration
of illness, number of prior consultation, age and number of
symptoms, suggesting that these are the most important
contributors for disability. The model was capable of explaining
35% of the variability of IDEAS [IDEAS = 2.08 + 0.17 * Prior
consultations + 0.2 * Symptoms + 0.08 * Age + 0.03 * Duration].
4. Discussion
In our study, three fourth of the patients with somatization
disorder suffered moderate to severe disability, and a positive

V. Kushwaha et al. / Asian Journal of Psychiatry 8 (2014) 5658

58

Table 2
Correlation of determinants of illness with IDEAS score (r).
IDEAS
IDEAS
Age
Duration
Symptoms
Consultations
HAM-D
HAM-A
PGIN2
VAS

1.0000
0.4793**
0.4672**
0.3601**
0.5280**
0.3333**
0.2985*
0.1377
0.1345

Age
1.0000
0.7489**
0.2699*
0.6009**
0.4548**
0.2633*
0.0202
0.0068

Duration

1.0000
0.2857*
0.6656**
0.4939**
0.2950*
0.0681
0.0005

Symptoms

1.0000
0.3229**
0.2803*
0.3404**
0.1319
0.2277

Consultations

1.0000
0.3635**
0.2431*
0.1168
0.0937

HAM-D

1.0000
0.4705**
0.1924
0.0801

HAM-A

1.0000
0.1308
0.3418**

PGI-N1

1.0000
0.0512

VAS

1.0000

r, Pearsons correlation; IDEAS, IDEAS score; duration, total duration of illness in years; symptoms, total number of somatic symptoms at present; consultations, lifetime total
number of consultations received; HAM-D, Hamilton Depression Rating scale; HAM-A, Hamilton Rating Scale for Anxiety; VAS, Visual Analog Scale.
*
Signicant correlation p < 0.05.
**
Signicant correlation p < 0.01.

correlation was observed between disability, and duration of


illness, number of somatization symptoms, number of prior
consultations, and anxiety and depression scores.
Somatization disorder has been associated with a number of
psychiatric disorders, commonest of which are depression and
anxiety (Gureje et al., 1997; Maier and Falkai, 1999; de Waal et al.,
2004). In our study, although patients did not have a syndromal
diagnosis of depression or anxiety disorder, a majority of them
scored high on HAM-D and HAM-A, and showed high distress and
neuroticism on the study measures.
A vast majority of the subjects suffered from moderate levels of
disability. More than 70% of our subjects were found to be
signicantly disabled. In comparison, only 64.3% of schizophrenics, 33% of patients with major depressive disorder, 30% of
patients with bipolar disorder and 16.7% of patients with anxiety
disorders were found to be signicantly disabled in an earlier
study using IDEAS on Indian patients (Chaudhury et al., 2006).
Another study from India, reported the mean IDEAS global score to
be 11.5 in patients with schizophrenia for less than 5 years
duration, and 3.13 in patients with obsessive compulsive disorder
of less than 5 years of duration (Mohan et al., 2005). Our patients of
somatization disorder were found to have IDEAS global score of
8.3  2.4 in comparison. Disability increased with age and the
number of symptoms, as also reported earlier (Harris et al., 2009).
Duration of illness, number of prior consultation, age and number of
symptoms, to be important contributors for disability, capable of
explaining 35% of the variability of IDEAS.
The study had a few limitations, including a cross sectional
design of the study and absence of a control sample for
comparison. The study did not analyze the domains of disability,
which might have resulted in further insights in the disability faced
by these patients.
Despite these limitations, our study is probably the rst study
from the Indian sub continent to report disability characteristics in
somatization disorder. It is also one of the few studies globally to
look into the somatization disorder and not somatization
symptoms or medically unexplained physical symptoms.
Conict of interest
None declared.

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